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On August 27,
2006, about 0606:35 eastern daylight time, Comair flight 5191, a
Bombardier CL-600-2B19, N431CA, crashed during takeoff from Blue Grass
Airport, Lexington, Kentucky. The flight crew was instructed to take off
from runway 22 but instead lined up the airplane on runway 26 and began
the takeoff roll. The airplane ran off the end of the runway and
impacted the airport perimeter fence, trees, and terrain.
The captain,
flight attendant, and 47 passengers were killed, and the first officer
received serious injuries. The airplane was destroyed by impact forces
and postcrash fire. The flight was operating under the provisions of 14
Code of Federal Regulations Part 121 and was en route to
According to a
customer service agent working in the Comair operations area, the flight
crew checked in for the flight at 0515. The agent indicated that the
crewmembers were casually conversing and were not yawning or rubbing
their eyes.
The flight crew
collected the flight release paperwork, which included weather
information, safety-of-flight notices to airmen (NOTAM), the tail number
of the airplane to be used for the flight, and the flight plan. The
flight crew then proceeded to an area on the air carrier ramp where two
Comair Canadair regional jet (CRJ) airplanes were parked.
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The cockpit voice
recorder (CVR) recording began about 0536:08. At that time, the flight
crew was conducting standard preflight preparations. About 0548:24, the
CVR recorded automatic terminal information service (ATIS) information
"alpha," which indicated that runway 22 was in use. About 1 minute
afterward, the first officer told the controller that he had received
the ATIS information.
About 0549:49, the
controller stated, "cleared to
The first officer
replied, "okay, got uh,
About 0552:04, the
captain began a discussion with the first officer about which of them
should be the flying pilot to ATL. The captain offered the flight to the
first officer, and the first officer accepted. About 0556:14, the
captain stated, "Comair standard," which is part of the taxi briefing,
and "run the checklist at your leisure."
About 0556:34, the
first officer began the takeoff briefing, which is part of the before
starting engines checklist. During the briefing, he stated, "he said
what runway ... two four," to which the captain replied, "it's two two."
The first officer
continued the takeoff briefing, which included three additional
references to runway 22. After briefing that the runway end identifier
lights were out, the first officer commented, "came in the other night
it was like ... lights are out all over the place." The first officer
also stated, "let's take it out and ... take ... [taxiway] Alpha. Two
two's a short taxi." The captain called the takeoff briefing complete
about 0557:40.
Starting about
0558:15, the first officer called for the first two items on the before
starting engines checklist. When the captain pointed out that the before
starting engines checklist had already been completed, the first officer
questioned, "we did"? Afterward, the first officer briefed the takeoff
decision speed (V1) as 137 knots and the rotation speed (VR) as 142
knots.
Flight data
recorder (FDR) data for the accident flight started about 0558:50. The
FDR showed that, at some point before the start of the accident flight
recording, the pilots' heading bugs had been set to 227º, which
corresponded to the magnetic heading for runway 22.
About 0559:14, the
captain stated that the airplane was ready to push back from the gate.
FDR data showed that, about 0600:08 and 0600:55, the left and right
engines, respectively, were started.
About 0602:01, the
first officer notified the controller that the airplane was ready to
taxi. The controller then instructed the flight crew to taxi the
airplane to runway 22. This instruction authorized the airplane to cross
runway 26 (the intersecting runway) without stopping. The first officer
responded, "taxi two two." FDR data showed that the captain began to
taxi the airplane about 0602:17. About the same time, SkyWest flight
6819 departed from runway 22.
About 0602:19, the
captain called for the taxi checklist. Beginning about 0603:02, the
first officer made two consecutive statements, "radar terrain displays"
and "taxi check's complete," that were spoken in a yawning voice. About
0603:38, American Eagle flight 882 departed from runway 22.
From about 0603:16
to about 0603:56, the flight crew engaged in conversation that was not
pertinent to the operation of the flight. About 0604:01, the first
officer began the before takeoff checklist and indicated again that the
flight would be departing from runway 22.
FDR data showed
that, about 0604:33, the captain stopped the airplane at the holding
position, commonly referred to as the hold short line, for runway 26.
Afterward, the first officer made an announcement over the public
address system to welcome the passengers and completed the before
takeoff checklist. About 0605:15, while the airplane was still at the
hold short line for runway 26, the first officer told the controller
that "Comair one twenty one" was ready to depart at his leisure; about 3
seconds later, the controller responded, "Comair one ninety one ... fly
runway heading. Cleared for takeoff." Neither the first officer nor the
controller stated the runway number during the request and clearance for
takeoff. FDR data showed that, about 0605:24, the captain began to taxi
the airplane across the runway 26 hold short line. The CVR recording
showed that the captain called for the lineup checklist at the same
time.
About 0605:40, the
controller transferred responsibility for American Eagle flight 882 to
the Indianapolis Air Route Traffic Control Center (ARTCC). FDR data
showed that, about 1 second later, Comair flight 5191 began turning onto
runway 26. About 0605:46, the first officer called the lineup checklist
complete.
About 0605:58, the
captain told the first officer, "all yours," and the first officer
acknowledged, "my brakes, my controls." FDR data showed that the
magnetic heading of the airplane at that time was about 266º, which
corresponded to the magnetic heading for runway 26. About 0606:05, the
CVR recorded a sound similar to an increase in engine rpm. Afterward,
the first officer stated, "set thrust please," to which the captain
responded, "thrust set." About 0606:16, the first officer stated,
"[that] is weird with no lights," and the captain responded, "yeah," 2
seconds later.
About 0606:24, the
captain called "one hundred knots," to which the first officer replied,
"checks." At 0606:31.2, the captain called, "V one, rotate," and stated,
"whoa," at 0606:31.8. FDR data showed that the callout for V1 occurred 6
knots early and that the callout for VR occurred 11 knots early; both
callouts took place when the airplane was at an airspeed of 131 knots.
FDR data also showed that the control columns reached their full aft
position about 0606:32 and that the airplane rotated at a rate of about
10º per second.
The airplane
impacted an earthen berm located about 265 feet from the end of runway
26, and the CVR recorded the sound of impact at 0606:33.0. FDR airspeed
and altitude data showed that the airplane became temporarily airborne
after impacting the berm but climbed less than 20 feet off the ground.
The CVR recorded
an unintelligible exclamation by a flight crewmember at 0606:33.3. FDR
data showed that the airplane reached its maximum airspeed of 137 knots
about 0606:35. The aircraft performance study for this accident showed
that, at that time, the airplane impacted a tree located about 900 feet
from the end of runway 26. The CVR recorded an unintelligible
exclamation by the captain at 0606:35.7, and the recording ended at
0606:36.2.
In a postaccident
interview, the controller stated that he did not see the airplane take
off. The controller also stated that, after hearing a sound, he saw a
fire west of the airport and activated the crash phone (the direct
communication to the airport's operations center and fire station) in
response.
The air traffic
control (ATC) transcript showed that the crash phone was activated about
0607:17 and that the airport operations center dispatcher responded to
the crash phone about 0607:22. According to the ATC transcript, the
controller announced an "alert three" and indicated that a Comair jet
taking off from runway 22 was located at the west side of the airport
just off the approach end of runway 8 (which is also the departure end
of runway 26). Section 1.15.1 discusses the emergency response.
Findings
1) The captain and
the first officer were properly certificated and qualified under Federal
regulations. There was no evidence of any medical or behavioral
conditions that might have adversely affected their performance during
the accident flight. Before reporting for the accident flight, the
flight crewmembers had rest periods that were longer than those required
by Federal regulations and company policy.
2) The accident
airplane was properly certified, equipped, and maintained in accordance
with Federal regulations. The recovered components showed no evidence of
any structural, engine, or system failures.
3) Weather was not
a factor in this accident. No restrictions to visibility occurred during
the airplane's taxi to the runway and the attempted takeoff. The taxi
and the attempted takeoff occurred about 1 hour before sunrise during
night visual meteorological conditions and with no illumination from the
moon.
4) The captain and
the first officer believed that the airplane was on runway 22 when they
taxied onto runway 26 and initiated the takeoff roll.
5) The flight crew
recognized that something was wrong with the takeoff beyond the point
from which the airplane could be stopped on the remaining available
runway.
6) Because the
accident airplane had taxied onto and taken off from runway 26 without a
clearance to do so, this accident was a runway incursion.
7) Adequate cues
existed on the airport surface and available resources were present in
the cockpit to allow the flight crew to successfully navigate from the
air carrier ramp to the runway 22 threshold.
8) The flight
crewmembers' nonpertinent conversation during the taxi, which was not in
compliance with Federal regulations and company policy, likely
contributed to their loss of positional awareness.
9) The flight
crewmembers failed to recognize that they were initiating a takeoff on
the wrong runway because they did not cross-check and confirm the
airplane's position on the runway before takeoff and they were likely
influenced by confirmation bias.
10) Even though
the flight crewmembers made some errors during their preflight
activities and the taxi to the runway, there was insufficient evidence
to determine whether fatigue affected their performance.
11) The flight
crew's noncompliance with standard operating procedures, including the
captain's abbreviated taxi briefing and both pilots' nonpertinent
conversation, most likely created an atmosphere in the cockpit that
enabled the crew's errors.
12) The controller
did not notice that the flight crew had stopped the airplane short of
the wrong runway because he did not anticipate any problems with the
airplane's taxi to the correct runway and thus was paying more attention
to his radar responsibilities than his tower responsibilities.
13) The controller
did not detect the flight crew's attempt to take off on the wrong runway
because, instead of monitoring the airplane's departure, he performed a
lower-priority administrative task that could have waited until he
transferred responsibility for the airplane to the next air traffic
control facility.
14) The controller
was most likely fatigued at the time of the accident, but the extent
that fatigue affected his decision not to monitor the airplane's
departure could not be determined in part because his routine practices
did not consistently include the monitoring of takeoffs.
15) The Federal
Aviation Administration's operational policies and procedures at the
time of the accident were deficient because they did not promote optimal
controller monitoring of aircraft surface operations.
16) The first
officer's survival was directly attributable to the prompt arrival of
the first responders; their ability to extricate him from the cockpit
wreckage; and his rapid transport to the hospital, where he received
immediate treatment.
17) The emergency
response for this accident was timely and well coordinated.
18) A standard
procedure requiring 14 Code of Federal Regulations Part 91K, 121, and
135 pilots to confirm and cross-check that their airplane is positioned
at the correct runway before crossing the hold short line and initiating
a takeoff would help to improve the pilots' positional awareness during
surface operations.
19) The
implementation of cockpit moving map displays or cockpit runway alerting
systems on air carrier aircraft would enhance flight safety by providing
pilots with improved positional awareness during surface navigation.
20) Enhanced
taxiway centerline markings and surface painted holding position signs
provide pilots with additional awareness about the runway and taxiway
environment.
21) This accident
demonstrates that 14 Code of Federal Regulations 91.129(i) might result
in mistakes that have catastrophic consequences because the regulation
allows an airplane to cross a runway during taxi without a pilot request
for a specific clearance to do so.
22) If controllers
were required to delay a takeoff clearance until confirming that an
airplane has crossed all intersecting runways to a departure runway, the
increased monitoring of the flight crew's surface navigation would
reduce the likelihood of wrong runway takeoff events.
23) If controllers
were to focus on monitoring tasks instead of administrative tasks when
aircraft are in the controller's area of operations, the additional
monitoring would increase the probability of detecting flight crew
errors.
24) Even though
the air traffic manager's decision to staff midnight shifts at Blue
Grass Airport with one controller was contrary to Federal Aviation
Administration verbal guidance indicating that two controllers were
needed, it cannot be determined if this decision contributed to the
circumstances of this accident.
25) Because of an
ongoing construction project at Blue Grass Airport, the taxiway
identifiers represented in the airport chart available to the flight
crew were inaccurate, and the information contained in a local notice to
airmen about the closure of taxiway A was not made available to the crew
via automatic terminal information service broadcast or the flight
release paperwork.
26) The
controller's failure to ensure that the flight crew was aware of the
altered taxiway A configuration was likely not a factor in the crew's
inability to navigate to the correct runway. 27) Because the information in the local notice to airmen (NOTAM) about the altered taxiway A configuration was not needed for the pilots' wayfinding task, the absence of the local NOTAM from the flight release paperwork was not a factor in this accident. 28) The presence of the extended taxiway centerline to taxiway A north of runway 8/26 was not a factor in this accident. |
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